In Reply: Dr Macleod argues that the conclusions
of our study linking caregiver strain to mortality are misleading due to confounding
with socioeconomic status, which he suggests was inadequately estimated by
duration of education. We chose education as a marker based on recent studies
showing it to be a particularly sensitive socioeconomic status indicator among
the elderly.1,2 We also
included other correlates of social position, such as race and other stressful
life events (including financial difficulties). Finally, in additional analyses
(not reported in our article), we added income level to the Cox regression
models, and this did not change the results for caregiving strain. Although
we agree with Macleod's point that caregiving has financial as well as physical
and emotional consequences, it does not follow, as he suggests, that our conclusions
are "misleading" and are "likely to lead to ineffective interventions." Our
findings show that identifying distressed older caregivers and alleviating
this distress may prevent morbid consequences including death.